The role of ceramide in the cellular response to cytotoxic agents

STUDY AIM: The aim of this study was to report the results of pharyngoesophageal reconstruction in extensive corrosive strictures and to describe an original conception concerning extensive chemical burns of the pharynx with involvement of the epiglottis, oro-hypopharyngeal junction and cricopharyngeal pinchcock. PATIENTS AND METHODS: A personal series of 253 esophageal reconstructions using the colon and ileum is reported. In 124 patients, the cervical anastomosis of the graft was performed at the level of the pharynx, and these cases with extensive pharyngeal lesions were the basis of this study. The anastomosis was performed with the hypopharynx in 27 patients, with the oropharynx in nine and a total reconstruction of the pharynx or "pharyngoplasty" was carried out in 69 patients. The pharyngoplasty was classified according to the approach, in anterior, posterior, lateral, superior (transmandibular) and inferior. In high strictures with epiglottic injury, epiglottectomy was necessary in order to prevent recurrence. A visceral pharyngoplasty was performed in 61 patients, using the colon in 42 and the ileum in 19, a skin reconstruction in six patients and a myocutaneous flap in two. RESULTS: The global postoperative mortality rate was 4.7%. Stenosis of the cervical anastomosis occurred in 4.9% of the whole series. With a follow-up from 6 months to 10 years, 70% of the patients resumed a normal oral diet, 21% had mild symptoms and 7% had poor results (patients with tracheostomy and gastrostomy). CONCLUSION: Extensive chemical burns of the pharynx are very severe and their treatment very difficult. For the author, total visceral pharyngeal reconstruction is considered to be the procedure of choice, using ileopharyngoplasty with realization of an ileal pouch. Good results were obtained in 70% of the patients with extensive corrosive strictures.     

Treatment of corrosive burns of the esophagus

Forty patients with caustic ingestion have been treated between 1955 and 1975. Strong alkali was the corrosive in 95%, and 80% were under 10 years old. Early esophageal stricture developed in 18 patients four weeks after lye ingestion. Among these, esophageal bougienge restored an adequate lumen in two patients with short, soft annular strictures, and right colon interposition was used for esophageal subsitution in ten who had long, dense strictures. We recommend early diagnostic esophagoscopy, to the uppermost level of burn injury only, to determine the presence and severity of the esophageal injury. If esophagoscopy reveals esophageal burn injury, corticosteroid and antibiotic therapy are continued. If no burn injury is visualized, the patient is spared unnecessary treatment. Long, dense strictures unresponsive to bougienage place the patient at risk from instrumental perforation, and these patients should undergo colon interposition through a substernal extrapleural tunnel.     

Gastric-tube esophagoplasty in children

From 1979 to 1996, 19 patients underwent gastric-tube esophagoplasty. There were 10 boys and 9 girls, aged between 1 year 4 months and 4 years 11 months at the time of surgery. In 1 patient the esophagoplasty was performed due to a long stenosis secondary to reflux; 3 others had caustic stenoses; and the remaining patients had esophageal atresia. In 17 cases an isoperistaltic gastric tube was brought up to the neck through the retrosternal space; in 2 an anisoperistaltic gastric tube was used, cervical mobilization being via the posterior mediastinum without a thoracotomy in 1 case and by the left transpleural route in the other. The cervical anastomosis was carried out in one surgical stage in 12 patients and in two stages in 7. In 1 patient the tube was resected due to necrosis of its proximal third; the child later underwent an esophagocoloplasty. Necrosis of the colic graft, mediastinitis, and septicemia occurred, leading to the only death in the series. There were 12 fistulas of the cervical anastomosis (63.3%) and 8 stenoses (42.1%). All fistulas, with 1 exception, closed spontaneously after 8 days to 2 months, and all stenoses were treated by endoscopic dilatation. Another patient developed a fistula of the gastric tube with chronic evolution to a stenosis of the distal third of the tube and communication with the right lower pulmonary lobe. A lobectomy and closure of the fistula were necessary. All patients were followed for a period of 1 to 16 years. At present, all of them swallow solid food normally. The evolution of the nutritional status was normal (eutrophic) in 14 of the 18 patients (77.7%) who survived the operation; 4 showed variable degrees of malnutrition. In 2 of these 4 cases the malnutrition was due to poor socioeconomic conditions, but was not related to the surgery. Redundancy, a problem associated with esophagocoloplasty, was not observed in any of the gastric tubes, which was attributed to the thickness of the gastric wall. The authors prefer the use of an isoperistaltic gastric tube (with proximal base) for esophageal replacement in children and recommend that the operation should be carried out when the child is able to swallow solid foods and walk. As in any other major surgical procedure, a good nutritional state is essential prior to operation.     

Catastrophic complications of the cervical esophagogastric anastomosis

Recent enthusiasm for the cervical esophagogastric anastomosis has arisen because of its perceived low morbidity. Although catastrophic complications of a cervical esophagogastric anastomosis are unusual, they can and do occur, and prevention is possible if the potential for them is recognized. Among 856 patients undergoing a cervical esophagogastric anastomosis after transhiatal esophagectomy, catastrophic cervical infectious complications occurred in 11 patients (1.3%): vertebral body osteomyelitis (1), epidural abscess with neurologic impairment (2), pulmonary microabscesses from internal jugular vein abscess (1), tracheoesophagogastric anastomotic fistula (1), and major dehiscence necessitating anastomotic takedown (6). These complications became manifest from 5 to 85 days after the esophageal resection and reconstruction (mean 19 days). Leakage from a gastric suspension stitch placed in the anterior spinal ligament over the vertebral bodies resulted in a posterior gastric leak and either osteomyelitis or an epidural abscess in three patients, none of whom had evidence of extravasation on the routine barium swallow 10 days after operation. Cervical exploration for a presumed anastomotic leak led to the unexpected discovery of an abscess formed by the stomach and the adjacent wall of the internal jugular vein, which was ligated and resected. One patient without symptoms who was discharged from the hospital with a contained anastomotic leak on the postoperative barium swallow was readmitted 7 days later with a cervical tracheoesophagogastric anastomotic fistula of which he ultimately died. In 6 patients (7% of those who had anastomotic leaks) there was sufficient gastric ischemia or necrosis, or both, to necessitate takedown of the anastomosis and intrathoracic stomach, cervical esophagostomy, and insertion of a feeding tube. As a result of this experience, it is recommended that cervical gastric suspension sutures either be omitted entirely or placed in the fascia over the longus colli muscles anterior to the spine, but not directly into the prevertebral fascia overlying the vertebral bodies or cervical disks. All but minute cervical anastomotic leaks, even if apparently contained, are best drained rather than treated expectantly. Patients who remain febrile and ill after bedside drainage of a cervical esophagogastric anastomosis leak should undergo cervical reexploration in the operating room; major gastric ischemia or necrosis, or both, may warrant takedown of the anastomosis and intrathoracic stomach.     

A case of polyangiitis overlap syndrome

PURPOSE: To examine the quality of life after repair of esophageal atresia, follow-up studies were performed in 58 of 71 surviving patients (81.7%). METHODS: Fifty patients with primary anastomosis and all eight surviving patients with colon interposition were seen. The mean age was 25.3 years (range, 20 to 31). Symptoms were evaluated by a standardized interview. Quality of life assessment was performed using a visual analogue scale (0 to 100 points), the Spitzer Index (5 dimensions, 10 points), and the Gastrointestinal Quality of Life Index (GIQLI, 5 dimensions, 128 points). RESULTS: After primary anastomosis the estimated meal capacity was unrestricted in 46 patients (92%), but numerous symptoms such as recidivating cough (60%), hold up (48%), and short breath (30%) were reported. All symptoms except cough were seen more frequently in patients with colon interposition, and all of these patients suffered from periods of short breath. Quality of life scores were higher in patients with primary anastomosis compared with colon interposition. The difference in the visual analogue scale score did not reach statistical significance, but the mean Spitzer Index was 9.7 compared with 8.8 after colon interposition (P < .05). The GIQLI after primary anastomosis was similar to that in healthy controls and was significantly lower in patients with colon interposition. This was because of specific symptoms, which scored 49.3 after colon interposition compared with 61.7 after primary anastomosis (P < .05) and to 54.8 (SD 5) in healthy controls (P < .05). Physical and social functions, emotions, and inconvenience of a medical treatment scored similar in patients with primary anastomosis, colon interposition, and healthy volunteers. CONCLUSIONS: The long-term quality of life after primary anastomosis was excellent. Patients with colon interposition suffer more frequently from various gastrointestinal and respiratory symptoms, but they lead an otherwise normal life.     

Comparison of vacuum extraction delivery between the conventional metal cup and the new soft rubber cup

The authors present a safe, conservative method of endless-loop bougienage (ELB) through the oral cavity and esophagus to a gastrostomy without general anesthesia in three children with corrosive esophageal burns treated since 1966. Esophagogastroscopy was performed to evaluate for esophagitis at an early phase after ingestion of the caustic substance. When esophageal stricture formation was recognized after subsequent conservative treatment, a feeding gastrostomy was made. A continuous string loop with plummets of progressively larger size was positioned to pass through the patient's oral cavity and esophagus to the gastrostomy. Strictures were found in the upper esophagus in two patients and in the middle and lower esophagus in one. The gastrostomy was performed 15 months, 20 days, and 2 months after the injury, respectively, and the periods of ELB were 3, 5, and 2(1/2) years, respectively. The patients were able to start eating at 26, 42, and 29 months after injury, respectively. They are now 30, 18, and 17 years old, and slight dysphagia remains in patients 1 and 2. No patient developed esophageal carcinoma at the site of the corrosive stricture. Our method of ELB through the patient's oral cavity and esophagus to the gastrostomy appears to be safe, reliable, and useful. We believe that most caustic esophageal strictures in children can be treated by this conservative measure.     

Esophageal conduit in nearly hopeless corrosive esophageal stricture patient

The case report of a 28 year old woman with strictured esophagus from corrosive esophagitis for 4 months is presented. Barium swallowing showed a strictured esophagus extending from T2 to the aortic knob and needed frequent dilatations. The patient had a perforated thoracic esophagus and mediastinitis on last dilatation. Cervical esophagostomy, transabdominal esophageal bandaging and jejunostomy feeding were done along with intravenous broad spectrum antibiotics. On esophagoscopy, there was complete stenosis of the cervical esophagus 2 cm from the postcricoid area. The large intestine from the caecum, transverse colon and descending colon was chosen as the esophageal conduit because of adequate length to pass subcutaneously. The caecum was anastomosed to the cervical esophagus and descending colon to the stomach. Seven days postoperatively, the patient could take liquids and soft porridge orally. There was a small leakage from the cervical anastomosed, spontaneous closure was achieved 3 weeks postoperatively. We chose the right side colon as the esophageal conduit because of adequate length to pass subcutaneously. Mediastinal and transhiatal routes could not be passed because of previous mediastinitis from thoracic esophageal perforation. This may be an alternative choice of operation for high cervical esophageal stenosis with previous mediastinitis.     

Dilatation of the left colon with a Foley catheter: an aid to staple anastomosis

Balloon dilatation of the left colon using a Foley catheter was performed in 26 patients prior to staple anastomosis. A 28-mm stapler was then used in six (23%) patients, a 29-mm in seven (27%), a 31-mm in eleven (42%) and a 33-mm in two (8%). Two anastomoses failed (7.9%) and one patient developed local recurrence. None of the remainder developed a symptomatic stricture. Flexible sigmoidoscopy was performed on 18 patients at least 3 months after surgery, revealing that one (5.5%) had developed an asymptomatic stricture. A 28-mm stapler had been used in this case. This technique of dilating the left colon with a Foley catheter is a useful aid to staple anastomosis in large bowel surgery.     

The NHS--taking a look back

The article summarizes 11 years' experience (1986-1997) of endoscopical treatment for scar strictures of esophageal anastomoses in 13 patients after various types of esophagoplasty. In 65% of patients the diameter of the anastomosis did not exceed 5 mm. For distension of the anastomoses bouginage, balloon dilation and both of them were used. All sorts of dilators were introduced through an endoscopically inserted guide. In one patient introduction of the guide was a failure. Endoscopical procedures were performed in 112 patients. The diameter of the anastomosis 14 mm and more was achieved in 40 (35.7%) patients, 10-13 mm--56 (50,0%), less than 10 mm--in 18 (14.3%). In one half of the patients restenosis developed 1-3 months after the treatment. As a prophylactic measure it is necessary to maintain regular treatment in outpatient clinic with increasing interval during 3-6 months using any available dilators of a large diameter.     

Ileorectal anastomosis: results of surgical treatment and evaluation of the intestinal function

Ileo-rectal anastomosis was performed in 30 patients. Indication for surgery was ulcerative colitis in 12, cancer of colon in 10 and megacolon in 6. Mean age of patients was 47.8 years with an even sex distribution. Ileo-rectal anastomosis was performed simultaneously with total colectomy in elective patients (n = 18) and at a second stage, following transient terminal ileostomy in emergency cases (n = 12). An overall morbidity of 26% was observed: wound infection developed in 13%, prolonged ileus in 7%, intraabdominal abscess in 3% and fistula of the anastomosis in 3%. There was no mortality. After a mean follow up of 36 months there was no instance of incontinence, average number of daily intestinal evacuations was 2.4 (somewhat higher for patients with ulcerative colitis: 2.6 vs 2.1). We conclude that ileo-rectal anastomosis is a safe procedure with adequate functional results.     

Total thoracic esophagectomy for esophageal cancer

BACKGROUND: Many current methods of esophageal resection have drawbacks that result in inadequate proximal resection, inadequate lymphadenectomy, and difficult gastric and splenic access. We describe a technique that allows reliable and safe access to the chest, abdomen, and neck. STUDY DESIGN: From 1988 to 1995, 113 patients (82 men; mean age 65.3 +/- 4.5 years) with carcinoma of the esophagus or esophagogastric junction (middle third in 34, lower third in 41, and cardia in 38) underwent total thoracic esophagectomy. The histology was adenocarcinoma in 71 (62.8%), squamous cell carcinoma in 32 (28.3%), and undifferentiated carcinoma in 10 (8.9%) of the patients; 57 tumors (50.5%) were stage III. The esophagus and stomach were mobilized through a left thoracoabdominal incision. After completion of the esophageal resection, the fundus of the stomach was sutured to the esophageal stump to allow later delivery of the stomach into the neck. The esophagogastric anastomosis was performed with continuous single-layer absorbable suture through a left oblique cervical incision. RESULTS: The mean duration of the operation was 309.2 +/- 47.9 minutes. Hospital stay ranged from 5 to 49 days (median, 12 days). The perioperative mortality rate was 4.4%. Anastomotic leak occurred in six patients (5.3%), one of whom died. The proximal resection margin was microscopically free of tumor in all cases, and with a minimum followup period of 18 months, there has been no anastomotic recurrence in any patient. Actuarial survival at 1 year was 63.4% +/- 4.9%, at 3 years 41.4% +/- 5.9%, and at 5 years 22.7% +/- 6.3%. CONCLUSIONS: Total thoracic esophagectomy through the left chest with a separate left cervical incision allows clear access to the esophagus and stomach and good tumor clearance. This procedure may be performed with a low rate of anastomotic leakage, a very low mortality rate, and no anastomotic tumor recurrence.     

Management of instrumental perforations of the esophagus occurring during treatment of corrosive strictures

BACKGROUND: The initial symptoms of esophageal perforations (EP) may be subtle, but the progression is very rapid, and the outcome may be disastrous unless the diagnosis is made early and proper treatment is started immediately. METHODS: Between 1976 and 1996, 1,249 patients with caustic esophageal burns were treated at Ege University. The study group is composed of 52 patients with instrumental ER Perforations occured during dilatation attempts of esophageal strictures. Twelve patients were referred from other institutions after the occurrence of EP. RESULTS: In two patients, emergency surgical repair of the perforation was possible. Seventeen patients with unilateral and two patients with bilateral empyema were treated by pleural drainages. Anterior retrosternal mediastinal drainage was needed in one patient, and 11 patients required posterior mediastinal drainages. Three patients were treated by both anterior and posterior mediastinal drainage. Tracheoesophageal fistulas (TEF) developed in eight patients immediately after a dilatation attempt. Seven of these patients required esophageal replacement with colon to bypass the fistulas, and one patient in this group healed spontaneously. EP healed in 42.5 +/- 49.4 days. Twelve (23%) patients died of mediastinitis and sepsis. CONCLUSION: When EP is diagnosed and treated with these methods, the mortality rate should approach zero.     

The endoscopic treatment of postoperative stenoses of the upper digestive tract

The authors compare their experience in dilatation of postoperative benign esophageal strictures. A total of 60 patients (37 males, 23 females: mean age 52), all with severe dysphagia, from January 1985 to September 1995, underwent endoscopic dilatation: 32 of these with Savary dilators and 28 with balloon dilators. Dilatation was effective in 93% in both groups. Two severe complications were recorded (1 heart attack and 1 perforation) in the group that underwent endoscopic dilatation with Savary dilators. During endoscopic management, pain recurred in 43% and 87% of cases after balloon or Savary dilatations, respectively. The authors believe balloon dilators are more effective, better tolerated and with less complications than Savary dilators. They reserve the management with Savary dilators to the extremely severe esophageal strictures.     

Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures

PURPOSE: We review the applications and outcomes of penile circular fasciocutaneous flap urethroplasty in 66 patients at our institution. MATERIALS AND METHODS: We used a circular distal penile skin flap for urethral reconstruction in 66 men with complex urethral strictures. Average stricture length in this series was 9.08 cm. and mean followup was 41 months (range 1 to 7 years). RESULTS: The initial overall success rate was 79% (52 of 66 cases). Recurrent stenosis was noted in 7 of the 54 onlay (13%) and 7 of the 12 tubularized repairs (58%). Most recurrent strictures were successfully treated with a single subsequent procedure, including repeat urethroplasty in 5 cases and optical urethrotomy or dilation in 6. Two patients required perineal urethrostomy and 1 awaits further reconstruction. Including subsequent procedures, the overall long-term followup success rate was 95%. Neurovascular lower extremity complications developed in 4 patients after prolonged high lithotomy positioning. CONCLUSIONS: Circular fasciocutaneous flap urethroplasty is a highly effective 1-stage method of reconstructing complex urethral strictures. Onlay repairs appear to be more successful than those involving flap tubularization. Limiting the time that the patient spends in the high lithotomy position appears to prevent neurovascular extremity complications.     

Indications, new surgical technique and results of colon interposition or bypass in esophageal surgery

Over a 5-year period, 29 patients with esophageal disease underwent colon interposition or bypass. The indication was cure of cancer in 11 patients, who underwent earlier a gastric resection. Other indications was benign stricture in 7 patients, bypass for unrespectable cancer in 6, having a caustic injury in 3 and after an esophageal perforation in 2. In 14 patients the left colon, in 15 the right colon was used. The colon was transected without dividing the mesentery other than just along its mesenteric border. This preserves additional blood supply from the marginal artery, also improves the function of the graft in transporting food. Anastomosis leakage occurred in 4 cases (13.7%). Graft necrosis occurred in 2 of 29 patients, one of whom alter underwent a successful second reconstruction. The 30 day operative mortality rate was 13.7%. A colon interposition provides good quality of deglution, and is the organ of choice for patients who require an esophageal substitute and are potential candidates for long survival, or when the stomach is unsuited for replacement or bypass.     

Esophagogastrostomy with the EEA stapler

Esophagogastric anastomosis was performed with the EEA stapler in 31 patients who underwent esophageal resections. Anastomoses were accomplished at all levels of the thoracic and cervical esophagus by a variety of approaches. Routine barium cine-esophagograms obtained at seven days after operation failed to demonstrate an anastomotic leak in any patient. The operative mortality rate was 3% (1 of 31 patients). Technical problems occurred during the operation in three patients; in two of these an incomplete anastomosis may have resulted from the surgeon's error. All patients were able to swallow normally at the time of discharge. Late anastomotic stricture occurred in five patients, and responded to dilatation in all but one patient who had local tumor recurrence. We conclude that the EEA stapler allows rapid and reliable esophagogastric anastomosis. Successful use of the instrument requires strict attention to technical detail and awareness of possible pitfalls.     

Surgical treatment of cicatricial biliary strictures

BACKGROUND/AIMS: Cicatricial biliary strictures are usually associated with high morbidity and mortality rates, frequently related to technical difficulties of their surgical repair, mainly in hilar lesions. Interference with bile duct blood supply during surgical attempts for correction is a major factor for unsuccessful results. The aim of this study is to evaluate, after an extended follow-up period, the results obtained with a modified technique for surgical correction of cicatricial biliary strictures. METHODOLOGY: The medical records of 57 patients surgically treated for cicatricial biliary strictures between January 1984 and July 1995 were reviewed and the immediate and long term results retrospectively analyzed. Patients consisted of 46 females and 11 males. The average age was 43 years. The etiology of the biliary lesion was: cholecystectomy alone (23); cholecystectomy with duct exploration (8); T tube CBD drainage (6); Biliary-enteric anastomosis stricture (16); choledochoplasty (2) and trauma (2). In 28 cases (49.1%) the stricture was located in the upper third of the bile duct, in 28 (49.1%) in the middle third and in one case (1.7%) it was low. All patients were submitted to longitudinal Roux-en-Y hepaticojejunostomy with mucosa apposition after dissection of the anterior aspect of the biliary tract. No transanastomotic stents were used. RESULTS: Ten patients (17.5%) presented 11 postoperative complications: biliary fistula (4), duodenal fistula (1), wound infection (5), and acute pancreatitis (1). Average hospital stay was 11 days and there were no postoperative mortalities. The follow-up study was possible in 54 patients and ranged from one to ten years, with an average of 2.9 years. Four patients of 28 (14%) with hilar lesions developed stricture recurrence and cholangitis episodes, whereas no patients bearing lesions below the biliary junction had such complications. CONCLUSION: Roux-en-Y hepaticojejunostomy with mucosa apposition without transanastomotic stent performed after minimal dissection of the biliary duct, thus avoiding major interference with the bile duct blood supply, is a safe and efficient method for the surgical repair of cicatricial biliary strictures. Using this technique excellent results can be obtained in the lesions below the biliary junction and acceptable results may be achieved in patients with hilar lesions.     

Rosaceous lymphedema: a rare variant of a common disorder

Surgical reconstruction of the trachea is a relatively complex procedure. We had 20 cases of tracheal stenosis. We have a modest experience of 16 tracheal reconstructions for acquired tracheal stenosis. Two patients underwent laser treatment while another two died before any intervention. The majority of these cases were a result of prolonged ventilation (14 cases), following organophosphorous poisoning (11 cases), Guillain-Barré syndrome, bullet injury, fat embolism and surprisingly only one tumor, a case of mucoepidermoid carcinoma, who had a very unusual presentation. There were 12 males and 4 females in this series, age ranging from 12-35 years. The duration of ventilation ranged from 1-21 days and the interval from decannulation to development of stridor was between 5-34 days. Six of them were approached by the cervical route, 5 by thoracotomy and cervical approach, 2 via median sternotomy and 3 by thoracotomy alone. Five of them required an additional laryngeal drop and 1 required pericardiotomy and release of pulmonary veins to gain additional length. The excised segments of trachea measured 3 to 5 cms in length. All were end to end anastomosis with interrupted Vicryl sutures. We have had no experience with stents or prosthetic tubes. Three patients developed anastomotic leaks which were controlled conservatively. Almost all of them required postoperative tracheo-bronchial suctioning with fibreoptic bronchoscope. We had one death in this series due to sepsis.     

Fact and artefact in confocal microscopy

PURPOSE: To analyze the results of a series of end-to-end urethroplasties performed in our service from 1968 to 1995 and of the factors contributing to failure. MATERIAL AND METHODS: 150 men (mean age 35.9 years) with urethral stricture disease underwent excision of the stricture and end-to-end anastomosis; in 95 it was the first attempt at repair while in 55 it was a secondary attempt. Eighty-two patients (54.6%) had a trauma-related stricture; of them, 56 followed a pelvic ring fracture with posterior urethra distraction defect, 24 (16%) had inflammatory strictures, 26 (17.3%) iatrogenic, 9 (6%) congenital, and 9 (6%) of unknown etiology; 81 (54%) were located in the bulbous urethra, 9 (6%) in the penoscrotal junction and 2 (1.3%) in the penile urethra. Ninety-one (60.6%) of the strictures or obliterative defects measured between 1 and 3 cm, 42 (28%) less than 1 cm and only 16 (10.6%) more than 3 cm. A perineal approach was used in 138 of the cases, while combined abdominoperineal route was necessary in 12; of these, 5 were children. The follow-up has ranged from 6 to 168 months (mean 44.4). The results were classified as good, fair (some re-stricturing, not needing treatment) and poor (recurrence). RESULTS: One hundred and twenty-six (84%) good outcomes, 10 (6.6%) fair, 14 (9.3%) poor. The factors influencing success or failure were: (1) primary or secondary character of the operation; (2) etiology; (3) length, and (4) location. Postoperative early complications consisted of 2 wound infections and 2 hematomas; as late complications, 1 chordee, 2 incontinence, 7 erectile dysfunction (in previously potent patients). The 14 patients considered as failures were operated again, all successfully; in 4 of them, a repeat excision and end-to-end anastomosis was performed, elevating the final success rate of the series to 93.3%. CONCLUSION: Excision and anastomotic repair represent the optimal mode of stricture repair for single lesions located from the penoscrotal junction to the membranous part of the urethra.     

Oxidation of D(-)3-hydroxybutyrate administered to rats with extensive burns

We present 28 patients who underwent surgery after failed procedures due to gastroesophageal reflux with an asymptomatic period over 2.6 years. The most frequent complications resulted in recurrent reflux (86%) and peptic strictures (36%). An abdominal approach was used on all the patients. Reoperation, using the Collis-Nissen gastroplasty (19 cases), Nissen 360 degrees (3 cases), duodenal diversion with Roux-en-Y (3 cases) and Angelchick prothesis (3 cases) gave excellent or good results in 84% of the patients and poor in 4 cases. There was one operative death. All patients were referred for 24 hour pH-monitoring. Sphincter pressure and length of the distal esophageal sphincter were significantly increased over the preoperative values. Our results suggest that the Collis Nissen procedure is a suitable form of treatment for complicated forms of peptic esophagitis after the failed antireflux operations.